Gap analysis for MDS functional status information and the HL7 Continuity of Care document (CCD) 

The functional status information from the MDS is: 

	Section B - Cognitive Patterns (7 day look back)
        Section C - Communication/Hearing Patterns (7 day look back)
	Section D - Vision (7 day look back)
	Section E - Mood and Behavior Patterns (7, 30 and 90 day look back depending on item being assessed)
	Section F - Psychosocial Well-Being (7 day look back)
	Section G - Physical Functioning and Structural Problems (7 day look back)
   	Section H - Continence In Last 14 Days (14 day look back except for change in Urinary Continence which 
                                                uses a 90 day look back)
	Section N - Activity Pursuit Patterns (7 Day look back)

While the scope of this project is limited to functional status, it should be noted that the MDS contains
additional assessment information that could prove useful in a full CCD mapping effort.  These sections include:
        Section AA - Identification Information
        Section AB - Demographic Information
        Section AC - Customary Routine
	Section A - MDS Identification and Background Information
	Section J - Health Conditions (7, 30, 90 and 180 day look back depending on item being assessed)
        Section K - Oral/Nutritional Status (7, 30 and 180 fay look back depending on item being assessed)
	Section M - Skin Condition (7 and 90 day look back depending on item being assessed)
	Section O - Medications (7 and 90 day look back depending on item being assessed)
	Section P - Special Treatments and Procedures (7, 14 and 90 day look back depending on item being assessed)

 
The overall process:	The standardization process proposed by Tom White et al. (1) is the framework for this
discussion.  The encoding steps for sending an MDS assessment would be:

Step 1: Encode to a standard coding system: Encode all MDS functional status items into LOINC (LOINCification)

Step 2: Concept Matching to a standard medical terminology: Where possible match LOINC codes of the MDS items 
with one or more equivalent terms from a standard medical terminology.  The suggested medical terminology is SNOMED.  Use semantic matching to do the matching.  Initially this is done using a panel of experts on OASIS and SNOMED.  

Step 3: Insert the LOINC codes of the MDS (and their SNOMED equivalents) into the functional status section 
of the CCD

Step 4 (Messaging): The CCD is an HL7 document (CDA) that is sent as a sequence of HL7 messages.





Work done on MDS:

Step 1 (LOINCification): The goal here is to capture the entire content of the assessment.  To do this, as with
other assessment instruments, MDS requires that certain information be stored with the responses.  

the entire assessment be encoded
each question, its text, special instructions, and order within the assessment
each response, its text, special instructions, and order within the question  
Versions: the ability to encode versions of any of the above.


LOINC has already done this for MDS by adding supplementary axes to LOINC(3)  


The supplementary axes are:
1.	SurveyQuestionText 
2.	AnswerList
3.	Formula
4.	SurveyQuestionSource
5.	Comments


Work on encoding the MDS into LOINC is substantially complete  

Step 2: (Semantic Matching)

Does SNOMED have all the terms to cover the concepts covered by MDS?

Some initial Work has been to done to identify "usefully related" SNOMED-CT terms with LOINC encoded MDS data.
(2) Carter J, White T., Harvell J Work will need to be completed for the MDS sections related to functional status
as identified above.     

	
Step 3: Insert the LOINC codes of the MDS (and their "usefully related" SNOMED CT Terms) into the functional status 
section of the CCD

The information will be placed into the Functional Status section of the ASTM/HL7 CCD.  

Is the syntax for the functional status section complete so that multiple semantic equivalents of a 
LOINC coded assessment response can be represented?


Step 4 (Messaging): The CCD is an HL7 document (CDA) that is sent as a sequence of HL7 messages.

Is  the work done for representing LOINC encoded MDS2  into an HL7 document (The CCD) sufficient for LOINC encoded MDS?  




(1) White, T, Harvell J,  et al. Modifying the HL7 Continuity of Care document (CCD) to Improve Reporting of Results form Functional Status Instruments. 
(2) Carter J, White T., Harvell J, Making the "Minimum Data Set" Compliant with Health Information Technology Standards.